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Definition

Transcatheter aortic valve replacement (TAVR) is a procedure used to replace the aortic valve without opening the chest. It is used to treat adults who aren't healthy enough for regular valve surgery.

The aorta is a large artery that carries blood from your heart to the rest of your body. Blood flows out of your heart and into the aorta through a valve. This valve is called the aortic valve. It opens up so blood can flow out. It then closes, keeping blood from flowing backwards.

An aortic valve that does not open fully will restrict blood flow. This is called aortic stenosis. If there is also a leak, it is called aortic regurgitation. Most aortic valves are replaced because they restrict flow forward through the aorta to the brain and body.

Description

The procedure will be done in a hospital. It will take about 2 to 4 hours.

• Before your surgery, you may receive general anesthesia. This will put you in a pain-free sleep. Most often, the procedure is done with you heavily sedated. You are not completely asleep but you do not feel pain. This is called moderate sedation.
• If general anesthesia is used, you will have a tube put down your throat connected to a machine to help you breathe. This is generally removed after the procedure. If moderate sedation is used, no breathing tube is needed.
• The cardiologist will make a cut (incision) in an artery in your groin or in your chest near your breast bone.
• If you don't already have a pacemaker, the cardiologist may put one in. You will wear it for 48 hours after the surgery. A pacemaker helps your heart beat in a regular rhythm.
• The cardiologist will thread a thin tube called a catheter through the artery to your heart and aortic valve.
• A small balloon on the end of the catheter will be expanded in your aortic valve. This is called the valvuloplasty.
• The cardiologist will then guide a new aortic valve over the catheter and balloon and place it in your aortic valve. A biological valve is used for TAVR.
• The new valve will be opened inside the old valve. It will do the work of the old valve.
• The cardiologist will remove the catheter and close the cut with stitches and a dressing.
• You do not need to be on a heart-lung machine for this procedure.

Why the Procedure Is Performed

TAVR is used for people with severe aortic stenosis who aren't healthy enough to have open chest surgery to replace a valve.

In adults, aortic stenosis is most often due to calcium deposits that narrow the valve. This generally affects older people.

TAVR may be done for these reasons:

• You are having major heart symptoms, such as chest pain (angina), shortness of breath, fainting spells (syncope), or heart failure.
• Tests show that changes in your aortic valve are beginning to seriously harm how well your heart works.
• You can't have regular valve surgery because it would put your health at risk. (Note: Studies are being performed to see whether more patients could be helped by the surgery.)

This procedure has many benefits. There is less pain, blood loss, and risk of infection. You will also recover faster than you would from open-chest surgery.

Risks

Risks of any anesthesia are:

• Bleeding
• Blood clots in the legs that may travel to the lungs
• Breathing problems
• Infection, including in the lungs, kidneys, bladder, chest, or heart valves
• Reactions to medicines

Other risks are:

• Damage to blood vessels
• You may need open heart surgery to correct complications that arise during the procedure
• Heart attack or stroke
• Infection of the new valve
• Kidney failure
• Abnormal heartbeat
• Bleeding
• Poor healing of incision
• Death

Before the Procedure

Always tell your health care provider what medicines you are taking, including over-the counter medicines, supplements, or herbs.

You should see your dentist before the procedure to make sure there are no infections in your mouth. If untreated, these infections may spread to your heart or new heart valve.

For the 2-week period before surgery, you may be asked to stop taking medicines that make it harder for your blood to clot. These might cause increased bleeding during the surgery.

• Some of them are aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn).
• If you are taking warfarin (Coumadin) or clopidogrel (Plavix), talk with your surgeon before stopping or changing how you take these drugs.

During the days before your procedure:

• Ask your cardiologist which medicines you should still take on the day of your procedure.
• If you smoke, you must stop. Ask your doctor for help.
• Always let your cardiologist know if you have a cold, flu, fever, herpes breakout, or any other illness in the time leading up to your procedure.
• On the day before your procedure, shower and shampoo well. You may be asked to wash your whole body below your neck with a special soap. Scrub your chest 2 or 3 times with this soap. You also may be asked to take an antibiotic to prevent infection.

On the day of your surgery:

• You will usually be asked not to drink or eat anything after midnight the night before your procedure. This includes chewing gum and using breath mints. Rinse your mouth with water if it feels dry, but be careful not to swallow.
• Take the medicines your cardiologist told you to take with a small sip of water.
• Your cardiologist will tell you when to arrive at the hospital.

After the Procedure

You can expect to spend 1 to 4 days in the hospital.

You will spend the first night in an intensive care unit (ICU). Nurses will monitor you closely. Usually within 24 hours, you will be moved to a regular room or a transitional care unit in the hospital.

The day after surgery, you will be helped out of bed so you can get up and move around. You may begin a program to make your heart and body stronger.

Your provider will show you how to care for yourself at home. You will learn how to bathe yourself and care for the surgical wound. You will also be given instructions for diet and exercise. Be sure to take any medicines as prescribed. You may need to take blood thinners for the rest of your life.

Your cardiologist will have you come in for a follow-up appointment to check that the new valve is working well.

Be sure to tell any of your providers that you have had a valve replacement. Be sure to do this before having any medical or dental procedures.

Outlook (Prognosis)

Having this procedure can improve the quality of your life and help you live longer than you might without the procedure. You may breathe easier and have more energy. You may be able to do things you couldn't do before because your heart is able to pump oxygen-rich blood to the rest of your body.

It's unclear how long the new valve will keep working, so be sure to see your doctor for regular appointments.

References

Arsalan M, Kim W-K, Walther T. Transcatheter aortic valve replacement. In: Sellke FW, Ruel M, eds. Atlas of Cardiac Surgical Techniques. 2nd ed. Philadelphia, PA: Elsevier; 2019:chap 16.

Leon MB, Mack MJ. Transcatheter aortic valve replacement. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia, PA: Elsevier; 2022:chap 74.

Lindman BR, Bonow RO, Otto CM. Aortic valve stenosis. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia, PA: Elsevier; 2022:chap 72.

Patel A, Kodali S. Transcatheter aortic valve replacement: indications, procedure, and outcomes. In: Otto CM, Bonow RO, eds. Valvular Heart Disease: A Companion to Braunwald's Heart Disease. 5th ed. Philadelphia, PA: Elsevier; 2021:chap 12.

Thourani VH, Iturra S, Sarin EL. Transcatheter aortic valve replacement. In: Sellke FW, del Nido PJ, Swanson SJ, eds. Sabiston and Spencer Surgery of the Chest. 9th ed. Philadelphia, PA: Elsevier; 2016:chap 79.

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